Rehab Revised: 2015 Changes to NFPA 1584

1. Rehab Revised: 2015 Changes to NFPA 1584Mike McEvoy, PhD, NRP, RN, CCRNEMS Chief – Saratoga County, New York

2. Rehab Revised:2015 Changes to NFPA 1584 Mike McEvoy, PhD, NRP, RN, CCRN EMS Chief – Saratoga County, NY EMS Editor – Fire Engineering magazine Board Member – IAFC EMS Section www.mikemcevoy.com

3. Rehab Resources www.firerehab.com

4. Disclosures • I am on the speakers bureau for Masimo Corporation • I do not intend to discuss any unlabeled or unapproved uses of drugs or products

5. McEvoy’s Philosophy: • Creation of 1584 (2008 version) • Prescriptive • Evidence basis

6. McEvoy’s Philosophy: • Creation of 1584 (2008 version) • Prescriptive • Evidence basis • Real world rehab • Historical perspective (baggage) • Who needs it?

7. McEvoy’s Philosophy: • Creation of 1584 (2008 version) • Prescriptive • Evidence basis • Real world rehab • Historical perspective (baggage) • Who needs it? • Effect on manpower / personnel pool @ scene

8. McEvoy’s Philosophy: • Creation of 1584 (2008 version) • Prescriptive • Evidence basis • Real world rehab • Historical perspective (baggage) • Who needs it • Effect on manpower / personnel pool @ scene • Firefighters = adults = performance athletes

9. NFPA Rehab Standard • Comment period open through 11/15/2013 • www.nfpa.org/1584

10. But we’re adults… Firefighters should know as much as professional athletes about rest, hydration, and endurance.

11. But we’re adults… Firefighters should know as much as professional athletes about rest, hydration, and endurance. Education on proper hydration, nutrition and diet

12. Firefighting • Greatest short surge physiologic demands of any profession. • 10% firefighter time spent on fireground • 50% of deaths & 66% of injuries occur on scene.

13. Firefighter LODDs – Likely Culprits: • Medical condition • Fitness • Rehab

14. What is Rehab? • “Restore condition of good health” • Mitigate effects of physical & emotional stress of firefighting: • Sustain or restore work capacity • Improve performance • Decrease injuries • Prevent deaths

15. Firefighter Rehab – NFPA 1584 • National Fire Protection Association 1584 “Standard on the Rehabilitation Process for Members During Emergency Operations and Training Exercises” • Originally issued in as recommendation in 2003, became a Standard in 2008, revision due for release in 2015. • Every department responsible to develop and implement rehab SOGs

16. Elements of Compliance • SOGs outline how rehab will be provided at incidents and training exercises (where FF expected to work 1 hour or more) • Minimum BLS level equipment on scene (= ambulance equipment) • Integrated into IMS

17. Elements of Compliance • SOGs outline how rehab will be provided at incidents and training exercises (where FF expected to work 1 hour or more) Commence whenever potential safety or health risk to members or risk exceeds safe level of physical or mental endurance.

18. NFPA 1584: 2015 Revisions Roles and Responsibilities delineated: • IC • CO • RehabManager • Members(FF)

19. NFPA 1584: 2015 Revisions Incident Commander: • Establish rehab • Assure staffing &supplies • Rotate members • Mental health services available to all members • If crew member seriously injured or killed, remove all crew members as soon as possible

20. NFPA 1584: 2015 Revisions Company Officer: • Awareness of FFphysical/mentalcondition • Assure hydration • Assess his/her company every 45 min • Wildland: evaluate heat stress conditions

21. NFPA 1584: 2015 Revisions Rehab Manager: • Operation,supplies • Food • Release • Records

22. NFPA 1584: 2015 Revisions Member: • Use rehab • Hydrate • Advise CO whenperformance affected • Awareness of others

23. NFPA 1584: 2015 Revisions Science Updates: • De-emphasis on sports drinks • Caffeine permitted up to 400 mg/day • Energy drinks banned • Passive cooling before active • Medical monitoringparameters are a local decision

24. Hydration and Prehydration • Firefighters are often dehydrated • Prehydrate for planned activities: • 500 ml fluid within 2 hours prior to event • Hydrate during events: • Water appropriate most of the time • Sports drinks after first hour of intense work or 3 hours total incident duration • Best to consume small amounts (60-120 ml) very frequently - Typical gastric emptying time limits fluid intake to no more than 1 liter per hour.

25. Hydration and Prehydration • Firefighters are often dehydrated • Prehydrate for planned activities: • 500 ml fluid within 2 hours prior to event • Hydrate during events: • Fluids: consume regardless of thirst, continue post incident • Sports drinks offered, consumed at FF discretion • Goal of completely replacing sweat loss deleted • Best to consume small amounts (60-120 ml) very frequently

26. Sports Drinks • Usually contain electrolytesand carbohydrates • Osmolarity (concentration) formulated for maximal absorption • Absorption limited by gastric emptying time (COH) • Dilution will extend gastric emptying time and lead to nausea / vomiting

27. Sports Drink Investigation • BMJ investigative report • 1035 web pages (listed in magazine ads), 431 performance-enhancing claims on 104 different products • 47.2% had references, none referred to systematic reviews (level 1 evidence) • 84% judged at high risk of bias • Only 3 (of 74) studies judged to be high quality and low risk of bias Heneghan C, Howick J, O’Neill B, Gill PJ, et al. The evidence underpinning sports performance products: a systematic assessment. BMJ Open 2012; 2:e001702. doi:10.1136/bmjopen-2012-001702

28. Sports Drink Investigation Conclusions: The current evidence is not of sufficient quality to inform the public about the benefits and harms of sports products. There is a need to improve the quality and reporting of research, a move towards using systematic review evidence to inform decisions.

29. Energy Drinks Definition: “A type of beverage containing stimulant drugs (caffeine, and other ingredients such as taurine, ginsign, guarana) that is marketed as providing mental or physical stimulation.” Not to be confused with Sports Drinks

30. NFPA 1584 - Overview • Ongoing education on when & how to rehab. • Provide supplies, shelter, equipment, and medical expertise to firefighters where and when needed. • Create a safety net for members unwilling or unable to recognize when fatigued.

31. Who’s Responsible for What? • Department: develop and implement SOGs • Company Officer: • Assess his/her crew every 45 minutes • Suggested after 2nd 30-min SCBA bottle • Or single 45- or 60-min bottle • Or after 40 min intense work without SCBA • Company Officers can adjust time frames to suit work or environmental conditions

32. What about informal rehab? • Was acceptable previously, now encouraged, particularly 1st round • Company or crew level rehab: • SCBA cylinder changes • Work transitions (firefighting to overhaul) • Small or routine incidents • When IC fails to recognize need for rehab

33. Informal Rehab Requirements: Fluids Shelter Place to remove PPE Seating for members

34. Nine Key Components of Rehab • Relief from climatic conditions • Rest and recovery • Cooling or rewarming • Re-hydration • Calorie and electrolyte replacement • Medical Monitoring • EMS tx according to local protocols • Member accountability • Release

35. 1. Relief from Climatic Conditions An area free from smoke and sheltered from extreme heat or cold is provided

36. 1. Relief from Climatic Conditions • Rehab unit or air conditioned vehicle/room • Portable heaters, enclosed unit • Removed, but not too far from incident • Vestibule area for removal and storage of PPE

37. 2. Rest and Recovery • Members afforded ability to rest for at least 10 minutes or as long as needed to recover work capacity

38. 2. Rest and Recovery • If not rested, rest for 10 more minutes. • Rest 20 min. on second rehab

39. 3. Cooling or Rewarming Better definition • Shaded or air conditioned area • Remove PPE • Gloves, helmet, hood, coat, open bunker pants (pull down to knees when seated) • Cool fluids • Rest

40. 3. Cooling or Rewarming • Passive cooling initially • Active cooling when passive ineffective or member exhibits heat related illness

41. Active Cooling: Cold Drinks • Cold Drinks • Serves dual purpose of hydration and cooling • Ability to cool may be limited on scene • Drinks usually stored warm - must be cooled or only benefit is hydration

42. Cold Towel – 3 Bucket System • Bucket 1: sanitizing solution • ¼ cup bleach/gallon • Bucket 2: rinse • Clear water removes any left over bleach • Bucket 3: regeneration • Ice water restores cooling effect

43. 4. Re-hydration • Potable fluidsto satisfy thirst on scene • Guidelines on beverages revised to allow caffeine up to 400 mg per day and prohibit energy drinks

44. 4. Re-hydration The truth about caffeine: • Increases urine output • Does not usually dehydrate(compensatory decline) • Consumption < 400 mg appears safe forfirefighters • Reference: EFO paper Stephen Abbott: Assessing the effect of energy drinks on firefighter health and safetywww.usfa.fema.gov/pdf/efop/efo45842.pdf

45. 4. Re-hydration • Fluid losses will often exceed gastric emptying limitations • No reliable method of assessing hydration status on scene • Weights • Urine specific gravity • ? Saliva testing

46. 4. Re-hydration Encourage continued hydrationpost-incident

47. 5. Calorie and electrolyte replacement • Rather than time (3+ hour event), now consider duration, exertion, time of last meal and individual conditions. • Whenever food is available, means to wash hands and faces must also be provided.

48. Food • Fruits, meal replacement bars, carbohydrate drinks (15 gm COH) • 30-60 grams carbohydrate per hour • High fat foods inappropriate

49. Medical Monitoring vs. Emergency Care Medical monitoring: observing members for adverse health effects (physical stress, heat or cold exposure, environmental hazards) Emergency Care: treatment for members with adverse effects or injury.

50. 6. Medical Monitoring in Rehab